Int J Colorectal Dis DOI 10.1007/s00384-015-2227-5
LETTER TO THE EDITOR
Intersphincteric infection due to an anal fissure Charlotte H. B. Deen-Molenaar 1 & Timo Jordanov 1 & Richelle J. F. Felt-Bersma 1,2
Accepted: 18 March 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor: Anal fissure is a linear ulcer in the squamous epithelium of the distal anal canal, usually located in the posterior midline. Its etiology is not clear yet, but the ischemic cause remains the most commonly supported theory. Pain during defecation is the main symptom indicated by patients, while on physical examination, spasm of the anal canal is a common finding. Although patients may complain of periodic episodes suggesting chronicity, most of the anal fissures at first presentation heal with lifestyle measures, laxatives, and local ointments. Chronicity is widely defined by both chronology and morphology. However, in spite of these treatments, some patients develop a chronic fissure, but so far, the real reason of unhealed fissures has not been investigated. In our practice, we have seen several cases where chronic anal fissure developed into an intersphincteric abscess. The literature is scarce about the subject. Three studies proposed a theory that a chronic anal fissure is the clinical and pathological expression of a coexisting intersphincteric or low transsphincteric fistula [1–3]. Herein, we present a case with anal ultrasound in which a chronic fissure developed into an abscess. A female patient who suffered from anal pain since 3 months was referred to our outpatient clinic. She stated that
* Richelle J. F. Felt-Bersma [email protected] Charlotte H. B. Deen-Molenaar [email protected] 1
Proctoskliniek, Prof Bronkhorstlaan 52, Building 10, 3723 MB Bilthoven, The Netherlands
2
Department of Gastroenterology and Hepatology, VU Medical Centre, PO Box 7057, 1007 MB Amsterdam, The Netherlands
the pain started after passing hard stools. Her general practitioner had treated her with mononitrate (diltiazem) ointment and macrogol. However, the anal pain persisted and occurred daily during defecation. Her medical history included asthma for which she used inhalation medication with corticosteroids. She had two vaginal births; during the first, an episiotomy was performed. At physical examination, there were no signs of general illness. The peri-anal skin was normal; there was no swelling. A fissure in the posterior midline was noticed. Rectal examination was hardly possible due to the pain, and hypertonia of the (internal) anal sphincter was present. During vaginal examination, there was no suspicion for any pararectal abscess nor signs of dyssynergy of the pelvic floor. Transanal ultrasound revealed a hypo-echogenic reflection in the mucosa that matched a fissure. The macrogol was continued, the topical treatment with diltiazem ointment increased to three times a day to be explicitly applied into the anus. Furthermore, we prescribed oral analgesics and explained the paradoxical functioning of the puborectal muscle during pain and the importance of avoiding straining. After 4 weeks, her pain had almost disappeared. She still used oral analgesics on demand but stopped using the diltiazem. Six weeks later, she returned because the pain had increased. At that time, the pain was continuously present despite the use of oral analgesics. Anal examination revealed a small sentinel polyp posteriorly and hypertonia of the (internal) anal sphincter. On transanal ultrasound, we now saw a hypo-echogenic area posteriorly suspicious for an intersphincteric infection. She was administered oral antibiotics (amoxicillin/clavulanic acid 625 mg), to be taken three times a day during 2 weeks. Three weeks later, she presented with ongoing pain and a painful swelling posterior of the anus. At rectal examination, a
Int J Colorectal Dis
painful opening was palpated in the posterior midline at 15 mm from the anal verge. On anal ultrasound, there was an increased intersphincteric hypo-echogenic lesion at the outer border of the internal anal sphincter with signs of an intersphincteric abscess. Initially, we drained the abscess at the outpatient clinic, but because of early recurrence after a week, we performed an exploration under general anesthesia. There was a posterior anal abscess, which originated from an internal fistula opening in the fissure. We drained the abscess and performed a fistulotomy. At follow-up 1 month later, the wound had healed and she had neither pain nor soiling. There were no signs of a recurrent abscess or fistula. It seemed as if the anal fissure, from which our patient suffered, had responded well to our designated therapy. However, after 6 weeks, it appeared as if the therapy had not been quite successful after all, and an intersphincteric infection had arisen. Unfortunately, despite recognition of the infection, we were not able to prevent deterioration using antibiotic therapy. Eventually, abscess drainage and fistulotomy was necessary. So far, a proven consistency between chronic anal fissure and intersphincteric abscess has not been established, but this case illustrates, in particular by the ultrasounds, that persistent or recurrent anal pain can be an indication for further diagnoses to exclude an intersphincteric infection. Naldini [1] described in a large survey that in 117 of 172 (65 %) of patients with a chronic anal fissure, an associated chronic abscess was found with anal ultrasound. These fistulas were intersphincteric in 91 and low transsphincteric in 21
patients. Gupta [2] described several associated pathologies in 88 patients with chronic anal fissures like abscesses (42 %), fistula’s (39 %), and antibioma (19 %). In that study, no anal ultrasound was performed; the final diagnoses were obtained during surgery. In conclusion, we think that chronic anal fissure is the clinical and pathological expression of a coexisting intersphincteric or low transsphincteric fistula. It is suggestive that an abscess or fistula can arise from an anal fissure, thus challenging in part the theory of the cryptoglandular concept. Moreover, we advocate that in a reliable number of patients suffering from chronic anal fissure, endoanal ultrasound should be performed routinely. Further studies regarding surgical results should confirm this theory and strengthen the position of anal ultrasound in the diagnostic path of chronic anal fissure. Therefore, we have instituted research into the relation between chronic anal fissures and peri-anal fistulas.
References 1.
2. 3.
Naldini G, Cerullo G, Mascagni D, Orlandi S, Menconi C, Zeri K, Felli E, Martellucci J (2012) Hiding intersphincteric and transsphincteric sepsis in a novel pathological approach to chronic anal fissure. Surg Innov 19:33–6 Gupta PJ (2005) A study of suppurative pathologies associated with chronic anal fissures. Tech Coloproctol 9:104–7 Parks AG, Thomson JP (1973) Intersphincteric abscess. Br Med J 2(5865):537–9
LETTER TO THE EDITOR
Intersphincteric infection due to an anal fissure Charlotte H. B. Deen-Molenaar 1 & Timo Jordanov 1 & Richelle J. F. Felt-Bersma 1,2
Accepted: 18 March 2015 # Springer-Verlag Berlin Heidelberg 2015
Dear Editor: Anal fissure is a linear ulcer in the squamous epithelium of the distal anal canal, usually located in the posterior midline. Its etiology is not clear yet, but the ischemic cause remains the most commonly supported theory. Pain during defecation is the main symptom indicated by patients, while on physical examination, spasm of the anal canal is a common finding. Although patients may complain of periodic episodes suggesting chronicity, most of the anal fissures at first presentation heal with lifestyle measures, laxatives, and local ointments. Chronicity is widely defined by both chronology and morphology. However, in spite of these treatments, some patients develop a chronic fissure, but so far, the real reason of unhealed fissures has not been investigated. In our practice, we have seen several cases where chronic anal fissure developed into an intersphincteric abscess. The literature is scarce about the subject. Three studies proposed a theory that a chronic anal fissure is the clinical and pathological expression of a coexisting intersphincteric or low transsphincteric fistula [1–3]. Herein, we present a case with anal ultrasound in which a chronic fissure developed into an abscess. A female patient who suffered from anal pain since 3 months was referred to our outpatient clinic. She stated that
* Richelle J. F. Felt-Bersma [email protected] Charlotte H. B. Deen-Molenaar [email protected] 1
Proctoskliniek, Prof Bronkhorstlaan 52, Building 10, 3723 MB Bilthoven, The Netherlands
2
Department of Gastroenterology and Hepatology, VU Medical Centre, PO Box 7057, 1007 MB Amsterdam, The Netherlands
the pain started after passing hard stools. Her general practitioner had treated her with mononitrate (diltiazem) ointment and macrogol. However, the anal pain persisted and occurred daily during defecation. Her medical history included asthma for which she used inhalation medication with corticosteroids. She had two vaginal births; during the first, an episiotomy was performed. At physical examination, there were no signs of general illness. The peri-anal skin was normal; there was no swelling. A fissure in the posterior midline was noticed. Rectal examination was hardly possible due to the pain, and hypertonia of the (internal) anal sphincter was present. During vaginal examination, there was no suspicion for any pararectal abscess nor signs of dyssynergy of the pelvic floor. Transanal ultrasound revealed a hypo-echogenic reflection in the mucosa that matched a fissure. The macrogol was continued, the topical treatment with diltiazem ointment increased to three times a day to be explicitly applied into the anus. Furthermore, we prescribed oral analgesics and explained the paradoxical functioning of the puborectal muscle during pain and the importance of avoiding straining. After 4 weeks, her pain had almost disappeared. She still used oral analgesics on demand but stopped using the diltiazem. Six weeks later, she returned because the pain had increased. At that time, the pain was continuously present despite the use of oral analgesics. Anal examination revealed a small sentinel polyp posteriorly and hypertonia of the (internal) anal sphincter. On transanal ultrasound, we now saw a hypo-echogenic area posteriorly suspicious for an intersphincteric infection. She was administered oral antibiotics (amoxicillin/clavulanic acid 625 mg), to be taken three times a day during 2 weeks. Three weeks later, she presented with ongoing pain and a painful swelling posterior of the anus. At rectal examination, a
Int J Colorectal Dis
painful opening was palpated in the posterior midline at 15 mm from the anal verge. On anal ultrasound, there was an increased intersphincteric hypo-echogenic lesion at the outer border of the internal anal sphincter with signs of an intersphincteric abscess. Initially, we drained the abscess at the outpatient clinic, but because of early recurrence after a week, we performed an exploration under general anesthesia. There was a posterior anal abscess, which originated from an internal fistula opening in the fissure. We drained the abscess and performed a fistulotomy. At follow-up 1 month later, the wound had healed and she had neither pain nor soiling. There were no signs of a recurrent abscess or fistula. It seemed as if the anal fissure, from which our patient suffered, had responded well to our designated therapy. However, after 6 weeks, it appeared as if the therapy had not been quite successful after all, and an intersphincteric infection had arisen. Unfortunately, despite recognition of the infection, we were not able to prevent deterioration using antibiotic therapy. Eventually, abscess drainage and fistulotomy was necessary. So far, a proven consistency between chronic anal fissure and intersphincteric abscess has not been established, but this case illustrates, in particular by the ultrasounds, that persistent or recurrent anal pain can be an indication for further diagnoses to exclude an intersphincteric infection. Naldini [1] described in a large survey that in 117 of 172 (65 %) of patients with a chronic anal fissure, an associated chronic abscess was found with anal ultrasound. These fistulas were intersphincteric in 91 and low transsphincteric in 21
patients. Gupta [2] described several associated pathologies in 88 patients with chronic anal fissures like abscesses (42 %), fistula’s (39 %), and antibioma (19 %). In that study, no anal ultrasound was performed; the final diagnoses were obtained during surgery. In conclusion, we think that chronic anal fissure is the clinical and pathological expression of a coexisting intersphincteric or low transsphincteric fistula. It is suggestive that an abscess or fistula can arise from an anal fissure, thus challenging in part the theory of the cryptoglandular concept. Moreover, we advocate that in a reliable number of patients suffering from chronic anal fissure, endoanal ultrasound should be performed routinely. Further studies regarding surgical results should confirm this theory and strengthen the position of anal ultrasound in the diagnostic path of chronic anal fissure. Therefore, we have instituted research into the relation between chronic anal fissures and peri-anal fistulas.
References 1.
2. 3.
Naldini G, Cerullo G, Mascagni D, Orlandi S, Menconi C, Zeri K, Felli E, Martellucci J (2012) Hiding intersphincteric and transsphincteric sepsis in a novel pathological approach to chronic anal fissure. Surg Innov 19:33–6 Gupta PJ (2005) A study of suppurative pathologies associated with chronic anal fissures. Tech Coloproctol 9:104–7 Parks AG, Thomson JP (1973) Intersphincteric abscess. Br Med J 2(5865):537–9
